2. Health status and trends

2.1. Life expectancy

Healthy life expectancy (HALE) at birth

Definition Average number of years that a person can expect to live in “full health” by taking into account years lived in less than full health due to disease and/or injury.

Rationale Substantial resources are devoted to reducing the incidence, duration and severity of major diseases that cause morbidity but not mortality and to reducing their impact on people’s lives. It is important to capture both fatal and non-fatal health outcomes in a summary measure of average levels of population health. Healthy life expectancy (HALE) at birth adds up expectation of life for different health states, adjusted for severity distribution making it sensitive to changes over time or differences between countries in the severity distribution of health states.

Life expectancy at birth (years)

Definition The average number of years that a newborn could expect to live, if he or she were to pass through life exposed to the sex- and age-specific death rates prevailing at the time of his or her birth, for a specific year, in a given country, territory, or geographic area.

Rationale Life expectancy at birth reflects the overall mortality level of a population. It summarizes the mortality pattern that prevails across all age groups - children and adolescents, adults and the elderly.

Life expectancy at age 60 (years)

Definition The average number of years that a person of 60 years old could expect to live, if he or she were to pass through life exposed to the sex- and age-specific death rates prevailing at the time of his or her 60 years, for a specific year, in a given country, territory, or geographic area.

Rationale Life expectancy at age 60 reflects the overall mortality level of a population over 60 years. It summarizes the mortality pattern that prevails across all age groups above 60 years.

2.2. Mortality

http://www.aho.afro.who.int/en/data-statistics/mortality

Adult mortality rate (probability of dying between 15 and 60 years per 1000 population)

Definition Probability that a 15 year old person will die before reaching his/her 60th birthday. The probability of dying between the ages of 15 and 60 years (per 1000 population) per year among a hypothetical cohort of 100 000 people that would experience the age-specific mortality rate of the reporting year.

Rationale Disease burden from non-communicable diseases among adults - the most economically productive age span - is rapidly increasing in developing countries due to ageing and health transitions. Therefore, the level of adult mortality is becoming an important indicator for the comprehensive assessment of the mortality pattern in a population.

Age-standardized mortality rate (per 100 000 population)

Definition The age-standardized mortality rate is a weighted average of the age-specific mortality rates per 100 000 persons, where the weights are the proportions of persons in the corresponding age groups of the WHO standard population.

Rationale The numbers of deaths per 100 000 population are influenced by the age distribution of the population. Two populations with the same age-specific mortality rates for a particular cause of death will have different overall death rates if the age distributions of their populations are different. Age-standardized mortality rates adjust for differences in the age distribution of the population by applying the observed age-specific mortality rates for each population to a standard population.

Estimated road traffic death rate (per 100 000 population)

Infant mortality rate (probability of dying between birth and age 1 per 1000 live births)

Definition Infant mortality rate is the probability of a child born in a specific year or period dying before reaching the age of one, if subject to age-specific mortality rates of that period.
Infant mortality rate is strictly speaking not a rate (i.e. the number of deaths divided by the number of population at risk during a certain period of time) but a probability of death derived from a life table and expressed as rate per 1000 live births.

Rationale Infant mortality represents an important component of under-five mortality. Like under-five mortality, infant mortality rates measure child survival. They also reflect the social, economic and environmental conditions in which children (and others in society) live, including their health care. Since data on the incidence and prevalence of diseases (morbidity data) frequently are unavailable, mortality rates are often used to identify vulnerable populations. Infant mortality rate is an MDG indicator.

Maternal mortality ratio (per 100 000 live births)

Definition The maternal mortality ratio (MMR) is the annual number of female deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 live births, for a specified year.

Rationale Complications during pregnancy, childbirth and post-partum are a leading cause of death and disability among women of reproductive age in developing countries. The maternal mortality ratio represents the risk associated with each pregnancy, i.e. the obstetric risk. It is also a Millennium Development Goal Indicator for monitoring Goal 5, improving maternal health.

The indicator monitors deaths related to pregnancy and childbirth. It reflects the capacity of the health systems to provide effective health care in preventing and addressing the complications occurring during pregnancy and childbirth

Under-five mortality rate (probability of dying by age 5 per 1000 live births)

Definition The probability of a child born in a specific year or period dying before reaching the age of five, if subject to age-specific mortality rates of that period. Under-five mortality rate as defined here is strictly speaking not a rate (i.e. the number of deaths divided by the number of population at risk during a certain period of time) but a probability of death derived from a life table and expressed as rate per 1000 live births.

Rationale Under-five mortality rate measures child survival. It also reflects the social, economic and environmental conditions in which children (and others in society) live, including their health care. Because data on the incidences and prevalence of diseases (morbidity data) frequently are unavailable, mortality rates are often used to identify vulnerable populations. Under-five mortality rate is an MDG indicator (see 3.1. MDG-4: Reduce child mortality).

2.3. Burden of disease

http://www.aho.afro.who.int/en/data-statistics/burden-disease

Distribution of years of life lost by major cause group (%)

Definition Distribution of years of life lost by 3 major cause group (communicable, maternal, neonatal and nutritional conditions; noncommunicable diseases; injuries), expressed as percentage of total of years of life lost.

Rationale Years of life lost (YLLs) take into account the age at which deaths occur by giving greater weight to deaths occurring at younger ages and lower weight to deaths occurring at older ages. The YLLs (percentage of total) indicator measures the YLLs due to a particular cause of death as a proportion of the total YLLs lost due to premature mortality in the population.

Under-five mortality rate (probability of dying by age 5 per 1000 live births)

3.2. MDG-5: Improve maternal health

Maternal mortality ratio (per 100 000 live births)

See under 5.6. Maternal and newborn health

Births attended par skilled health personnel (%)

See 5.6. Maternal and newborn health

Antenatal care coverage – at least one visit (%)

Definition The percentage of women aged 15-49 with a live birth in a given time period that received antenatal care provided by skilled health personnel (doctors, nurses, or midwives) at least once during pregnancy. Numerator: The number of women aged 15-49 with a live birth in a given time period that received antenatal care provided by skilled health personnel (doctors, nurses or midwives) at least once during pregnancy. Denominator: Total number of women aged 15-49 with a live birth in the same period.

3.7. MDG-3: Promote gender equality and empower women

Gender parity index in primary education

Definition Ratio of girls to boys (gender parity index) in primary, secondary and tertiary education is the ratio of the number of female students enrolled at primary, secondary and tertiary levels of education to the number of male students in each level. To standardise the effects of the population structure of the appropriate age groups, the Gender Parity Index (GPI) of the Gross Enrolment Ratio (GER) for each level of education is used. The GER is the number of pupils enrolled in a given level of education, regardless of age, expressed as a percentage of the population in the theoretical age group for the same level of education.

Rationale To calculate the Gross Enrolment Ratio one must first determine the population of official school age for each level of education by reference to the theoretical starting ages and durations of the International Standard Classification of Education (ISCED97) Level 1 (primary education) and Levels 2 and 3 (secondary education) as reported by the country. The population of the official age for tertiary education is the 5-year age group immediately following the end of secondary education.

Then, the number of pupils or students enrolled in each level of education is divided by the population of official school age for that level of education, and the result is multiplied by 100. The Gross Enrolment Ratios for males and females are calculated separately.

The Gender Parity Index (GPI) is then calculated by dividing the female Gross Enrolment Ratio by the male Gross Enrolment Ratio for the given level of education.

This method requires information on the structure of education (i.e. theoretical entrance age and duration of ISCED97 Level 1 and Levels 2 and 3), enrolments in each level of education and the populations of the age-groups corresponding to the given levels of education. Separate figures for males and females are required.

Official development assistance (ODA) received as percentage of GDP

4. The health system

4.1. Health system outcomes

http://www.aho.afro.who.int/en/data-statistics/health-system-outcomes

Antenatal care coverage – at least one visit (in the two years preceding the survey) (%)

Definition The percentage of women aged 15-49 with a live birth in a given time period that received antenatal care provided by skilled health personnel (doctors, nurses, or midwives) at least once during pregnancy. Numerator: the number of women aged 15-49 with a live birth in a given time period that received antenatal care provided by skilled health personnel (doctors, nurses or midwives) at least once during pregnancy. Denominator: total number of women aged 15-49 with a live birth in the same period.

Antenatal care coverage – at least one visit (in the three years preceding the survey) (%)

Definition The percentage of women aged 15-49 with a live birth in a given time period that received antenatal care provided by skilled health personnel (doctors, nurses, or midwives) at least once during pregnancy. Numerator: The number of women aged 15-49 with a live birth in a given time period that received antenatal care provided by skilled health personnel (doctors, nurses or midwives) at least once during pregnancy. Denominator: Total number of women aged 15-49 with a live birth in the same period.

Antenatal care coverage – at least one visit (in the five years preceding the survey) (%)

Definition The percentage of women aged 15-49 with a live birth in a given time period that received antenatal care provided by skilled health personnel (doctors, nurses, or midwives) at least once during pregnancy. Numerator: The number of women aged 15-49 with a live birth in a given time period that received antenatal care provided by skilled health personnel (doctors, nurses or midwives) at least once during pregnancy. Denominator: Total number of women aged 15-49 with a live birth in the same period.

Antenatal care coverage – at least four visits (in the two years preceding the survey) (%)

Definition Percentage of women aged 15–49 with a live birth in a given time period, attended at least four times during pregnancy by any provider (skilled or unskilled) for reasons related to the pregnancy. Numerator: Number of women aged 15–49 with a live birth in a given time period, attended at least four times during pregnancy by any provider (skilled or unskilled) for reasons related to the pregnancy – only the last live-born child is considered. Denominator: Total number of women aged 15–49 who had a live birth occurring in the same period.

Antenatal care coverage – at least four visits (in the three years preceding the survey) (%)

Definition Percentage of women aged 15–49 with a live birth in a given time period, attended at least four times during pregnancy by any provider (skilled or unskilled) for reasons related to the pregnancy. Numerator: Number of women aged 15–49 with a live birth in a given time period, attended at least four times during pregnancy by any provider (skilled or unskilled) for reasons related to the pregnancy – only the last live-born child is considered. Denominator: Total number of women aged 15–49 who had a live birth occurring in the same period.

Antenatal care coverage - at least four visits (in the five years preceding the survey) (%)

Definition Percentage of women aged 15–49 with a live birth in a given time period, attended at least four times during pregnancy by any provider (skilled or unskilled) for reasons related to the pregnancy. Numerator: Number of women aged 15–49 with a live birth in a given time period, attended at least four times during pregnancy by any provider (skilled or unskilled) for reasons related to the pregnancy – only the last live-born child is considered. Denominator: Total number of women aged 15–49 who had a live birth occurring in the same period.

Births attended by skilled health personnel (in the two years preceding the survey) (%)

Definition Percentage of live births attended during delivery by skilled health personnel. Skilled health personnel includes doctors, nurses, midwives and other medically trained personnel as defined according to each country. This is in line with the definition used by the Countdown to 2015 Collaboration, DHS and MICS. Numerator: Number of live births to women aged 15-49 years attended during delivery by skilled health personnel in the period prior to the survey. Denominator: Total number of live births to women aged 15-49 years occurring in the period prior to the survey.

Births attended by skilled health personnel (in the three years preceding the survey) (%)

Definition Percentage of live births attended during delivery by skilled health personnel. Skilled health personnel includes doctors, nurses, midwives and other medically trained personnel as defined according to each country. This is in line with the definition used by the Countdown to 2015 Collaboration, DHS and MICS. Numerator: Number of live births to women aged 15-49 years attended during delivery by skilled health personnel in the period prior to the survey. Denominator: Total number of live births to women aged 15-49 years occurring in the period prior to the survey.

Births attended by skilled health personnel (in the five years preceding the survey) (%)

Definition Percentage of live births attended during delivery by skilled health personnel. Skilled health personnel includes doctors, nurses, midwives and other medically trained personnel as defined according to each country. This is in line with the definition used by the Countdown to 2015 Collaboration, DHS and MICS. Numerator: Number of live births to women aged 15-49 years attended during delivery by skilled health personnel in the period prior to the survey. Denominator: Total number of live births to women aged 15-49 years occurring in the period prior to the survey.

Family planning needs satisfied (%)

Definition Percentage of women aged 15–49 years, married or in union, who are currently using any method of contraception, among those in need of contraception. Women in need of contraception include those who are fecund but report wanting to space their next birth or stop childbearing altogether. Numerator: Number of women aged 15–49 that are fecund and are married or in union and need contraception, who use any kind of contraceptive (modern or traditional). Denominator: Total number of women aged 15–49 that are fecund and are married / have a partner and need contraception.

4.5. Research

4.6. Health financing

External resources for health as a percentage of total expenditure on health

Definition External resources for health expressed as a percentage of total expenditure on health.

Rationale This is a core indicator of health financing systems. Most indicators presented in NHA involve a measurement at the level of purchaser/payer of health services. This is, however, an indicator which refers to the origin of the resources used to purchase health services. It is the only information about the sources of funds provided in these tables. The other indicators - GGHE, PvtHE etc. - are financing agents, the entities where the use of the funds are controlled. Some of these external sources will be channeled through the government’s budget, some through insurance agencies, some through the private or NGO sectors. As such, these funds cannot simply be added to those reported in the earlier breakdowns. In the special case where external agencies act as domestic NGOs in providing or purchasing health care in a recipient country, they would be included as financing agents as well as a source. We provide here only the source level measurement. The analysis of financing sources contributes to identify the distribution of the financing burden of health services. This indicator contributes to assess sustainability of financing.

General government expenditure on health as a percentage of total expenditure on health

Definition Level of general government expenditure on health (GGHE) expressed as a percentage of total expenditure on health (THE)

Rationale This is a core indicator of health financing systems. This indicator contributes to understanding the relative weight of public entities in total expenditure on health. It includes not just the resources channeled through government budgets to providers of health services but also the expenditure on health by parastatals, extrabudgetary entities and notably the compulsory health insurance payments. It refers to resources collected and pooled by the above public agencies regardless of the source, so includes any donor (external) funding passing through these agencies.

General government expenditure on health as a percentage of total government expenditure

Definition Level of general government expenditure on health (GGHE) expressed as a percentage of total government expenditure.

Rationale This is a core indicator of health financing systems. This indicator contributes to understand the weight of public spending on health within the total value of public sector operations. It includes not just the resources channelled through government budgets but also the expenditure on health by parastatals, extrabudgetary entities and notably the compulsory health insurance. It refers to resources collected and pooled by public agencies including all the revenue modalities.

Per capita government expenditure on health (PPP int. $)

Definition Per capita general government expenditure on health (GGHE) expressed in PPP international dollar

Rationale This is a core indicator of health financing systems. This indicator contributes to understand the relative level of public spending on health to the beneficiary population, expressed in international dollars to facilitate international comparisons. It includes not just the resources channeled through government budgets but also the expenditure on health by parastatals, extrabudgetary entities and notably the compulsory health insurance. It refers to resources collected and polled by public agencies including all the revenue modalities.

Per capita government expenditure on health at average exchange rate (US$)

Definition Per capita general government expenditure on health (GGHE) expressed at average exchange rate for that year in US dollar. Current prices.

Rationale This is a core indicator of health financing systems. This indicator contributes to understand the relative level of public spending on health to the beneficiary population, expressed in US$ to facilitate international comparisons. It includes not just the resources channeled through government budgets but also the expenditure on health by parastatals, extrabudgetary entities and notably the compulsory health insurance. It refers to resources collected and pooled by public agencies including all the revenue modalities.

Per capita total expenditure on health (PPP int. $)

Definition Per capita total expenditure on health (THE) expressed in PPP international dollar.

Rationale This is a core indicator of health financing systems. This indicator contributes to understand the total expenditure on health relative to the beneficiary population, expressed in Purchasing Power Parities (PPP) to facilitate international comparisons.

Per capita total expenditure on health at average exchange rate (US$)

Definition Per capita total expenditure on health (THE) expressed at average exchange rate for that year in US$. Current prices.

Rationale This is a core indicator of health financing systems. This indicator contributes to understand the total expenditure on health relative to the beneficiary population, expressed in USD to facilitate international comparisons.

Social security expenditure on health as a percentage of general government expenditure on health

Definition Level of social security funds expressed as a percentage of general government expenditure on health.

Rationale This is a core indicator of health financing systems. This indicator contributes to understanding the relative weight of prepaid pooled schemes in GGHE. This indicator refers to the health expenditures by government social security schemes and other schemes of compulsory health insurance. Any donor (external) funds channeled through these institutions are included.

4.7. Service delivery

Definition The proportion of new smear-positive TB cases registered under a national TB control programme in a given year that successfully completed treatment, whether with or without bacteriological evidence of success (“cured” or “treatment completed” respectively). At the end of treatment, each patient is assigned one of the following six mutually exclusive treatment outcomes: cured; completed; died; failed; defaulted; and transferred out with outcome unknown. The proportions of cases assigned to these outcomes, plus any additional cases registered for treatment but not assigned to an outcome, add up to 100% of cases registered.

Rationale Treatment success is an indicator of the performance of national TB control programmes. In addition to the obvious benefit to individual patients, successful treatment of infectious cases of TB is essential to prevent the spread of the infection. Detecting and successfully treating a large proportion of TB cases should have an immediate impact on TB prevalence and mortality. By reducing transmission, successfully treating the majority of cases will also affect, with some delay, the incidence of disease. Indicator 6.10 of the Millenium development Goal is the “proportion of tuberculosis cases detected and cured under DOTS”. The Stop TB Partnership’s Global Plan to Stop TB 2011 - 2015 has set a target of smear-positive treatment success rate of 90%.

Definition The proportion of new smear-negative and extrapulmonary (or smear unknown/not done) TB cases registered under a national TB control programme in a given year that successfully completed treatment (without bacteriological evidence of success, ie “treatment completed”). At the end of treatment, each patient is assigned one of the following five mutually exclusive treatment outcomes: completed; died; failed; defaulted; and transferred out with outcome unknown. The proportions of cases assigned to these outcomes, plus any additional cases registered for treatment but not assigned to an outcome, add up to 100% of cases registered.

Rationale Treatment success is an indicator of the performance of national TB control programmes. In addition to the obvious benefit to individual patients, successful treatment of infectious cases of TB is essential to prevent the spread of the infection. Detecting and successfully treating a large proportion of TB cases should have an immediate impact on TB prevalence and mortality. By reducing transmission, successfully treating the majority of cases will also affect, with some delay, the incidence of disease.

Treatment success rate for retreatment tuberculosis cases

Definition The proportion of cases with previous TB treatment history registered under a national TB control programme in a given year that successfully completed treatment, whether with or without bacteriological evidence of success (“cured” or “treatment completed” respectively). At the end of treatment, each patient is assigned one of the following six mutually exclusive treatment outcomes: cured; completed; died; failed; defaulted; and transferred out with outcome unknown. The proportions of cases assigned to these outcomes, plus any additional cases registered for treatment but not assigned to an outcome, add up to 100% of cases registered.

Rationale Treatment success is an indicator of the performance of national TB control programmes. In addition to the obvious benefit to individual patients, successful treatment of infectious cases of TB is essential to prevent the spread of the infection. Detecting and successfully treating a large proportion of TB cases should have an immediate impact on TB prevalence and mortality. By reducing transmission, successfully treating the majority of cases will also affect, with some delay, the incidence of disease.

4.8. Health workforce

Definition Number of community and traditional health workers per 1 000 population.

Rationale Preparing the health workforce to work towards the attainment of a country’s health objectives represents one of the most important challenges for its health system. Methodologically, there are no gold standards for assessing the sufficiency of the health workforce to address the health care needs of a given population. It has been estimated however, in the World Health Report 2006, that countries with fewer than 23 physicians, nurses and midwives per 10 000 population generally fail to achieve adequate coverage rates for selected primary health care interventions as prioritized by the Millennium Development Goals framework.

Dentistry personnel density (per 1000 population)

Definition Number of dentistry personnel per 1 000 population.

Rationale Preparing the health workforce to work towards the attainment of a country’s health objectives represents one of the most important challenges for its health system. Methodologically, there are no gold standards for assessing the sufficiency of the health workforce to address the health care needs of a given population. It has been estimated however, in the World Health Report 2006, that countries with fewer than 23 physicians, nurses and midwives per 10 000 population generally fail to achieve adequate coverage rates for selected primary health care interventions as prioritized by the Millennium Development Goals framework.

Environmental and public health workers density (per 1000 population)

Definition Number of environment and public health workers per 1 000 population.

Rationale Preparing the health workforce to work towards the attainment of a country’s health objectives represents one of the most important challenges for its health system. Methodologically, there are no gold standards for assessing the sufficiency of the health workforce to address the health care needs of a given population. It has been estimated however, in the World Health Report 2006, that countries with fewer than 23 physicians, nurses and midwives per 10 000 population generally fail to achieve adequate coverage rates for selected primary health care interventions as prioritized by the Millennium Development Goals framework.

Laboratory health workers density (per 1 000 population)

Definition Number of laboratory health workers per 1 000 population.

Rationale Preparing the health workforce to work towards the attainment of a country’s health objectives represents one of the most important challenges for its health system. Methodologically, there are no gold standards for assessing the sufficiency of the health workforce to address the health care needs of a given population. It has been estimated however, in the World Health Report 2006, that countries with fewer than 23 physicians, nurses and midwives per 10 000 population generally fail to achieve adequate coverage rates for selected primary health care interventions as prioritized by the Millennium Development Goals framework.

Nursing and midwifery personnel density (per 1000 population)

Definition Number of nursing and midwifery personnel per 1 000 population.

Rationale Preparing the health workforce to work towards the attainment of a country’s health objectives represents one of the most important challenges for its health system. Methodologically, there are no gold standards for assessing the sufficiency of the health workforce to address the health care needs of a given population. It has been estimated however, in the World Health Report 2006, that countries with fewer than 23 physicians, nurses and midwives per 10 000 population generally fail to achieve adequate coverage rates for selected primary health care interventions as prioritized by the Millennium Development Goals framework.

Other health workers density (per 1000 population)

Definition Number of other health service providers (excepting physicians, nursing and midwifery personnel, dentistry personnel and community health workers) per 1 000 population.

Rationale Preparing the health workforce to work towards the attainment of a country’s health objectives represents one of the most important challenges for its health system. Methodologically, there are no gold standards for assessing the sufficiency of the health workforce to address the health care needs of a given population. It has been estimated however, in the World Health Report 2006, that countries with fewer than 23 physicians, nurses and midwives per 10 000 population generally fail to achieve adequate coverage rates for selected primary health care interventions as prioritized by the Millennium Development Goals framework.

Pharmaceutical personnel density (per 1000 population)

Definition Number of pharmaceutical personnel per 1 000 population

Rationale Preparing the health workforce to work towards the attainment of a country’s health objectives represents one of the most important challenges for its health system. Methodologically, there are no gold standards for assessing the sufficiency of the health workforce to address the health care needs of a given population. It has been estimated however, in the World Health Report 2006, that countries with fewer than 23 physicians, nurses and midwives per 10 000 population generally fail to achieve adequate coverage rates for selected primary health care interventions as prioritized by the Millennium Development Goals framework.

Physicians density (per 1000 population)

Definition Number of medical doctors (physicians), including generalist and specialist medical practitioners, per 1 000 population.

Rationale Preparing the health workforce to work towards the attainment of a country’s health objectives represents one of the most important challenges for its health system. Methodologically, there are no gold standards for assessing the sufficiency of the health workforce to address the health care needs of a given population. It has been estimated however, in the World Health Report 2006, that countries with fewer than 23 physicians, nurses and midwives per 10 000 population generally fail to achieve adequate coverage rates for selected primary health care interventions as prioritized by the Millennium Development Goals framework.

Total density per 100 000 population: Health centres

Total density per 100 000 population: Health posts

Definition Number of health posts from the public and private sectors, per 100,000 population. Health posts are either community centres or health environments with a very limited number of beds with limited curative and preventive care resources normally assisted by health workers or nurses.

Median availability of selected generic medicines (%)

Rationale Access to treatment is heavily dependent on the availability of affordable medicines. A regular, sustainable supply of essential medicines is required to avoid medicine shortages that can cause avoidable suffering and death. This indicator is part of a series of 9 indicators proposed by WHO to measure MDG Target 8.E: In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries.

Median consumer price ratio of selected generic medicines

Rationale Medicines account for 20-60% of health spending in developing and transitional countries. Furthermore, up to 90% of the population in developing countries purchase medicines through out-of-pocket payments, making medicines the largest family expenditure item after food. As a result, medicines are unaffordable for large sections of the global population and are a major burden on government budgets. This indicator is part of a series of 9 indicators proposed by WHO to measure MDG Target 8.E: In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries.

Total density per million population: Radiotherapy units

Definition Number of radiotherapy units, including Linear Accelerators and Cobalt-60 from the public and private sectors, per 1 000 000 population.

Rationale In 2010, WHO launched a Baseline country survey on medical devices that allowed to identify the status of high cost medical devices in the Member States, including radiotherapy equipment, both linear accelerators and Cobalt-60. Cancer is a leading cause of death worldwide, killing nearly eight million people a year. Yet about one-third of these lives could be saved if cancer is detected and treated early. Three-quarters of cancer deaths occur in developing countries where the resources needed to prevent, diagnose and treat cancer are severely limited or nonexistent. Consequently, it is important to know the gaps in availability in order to find programmes to improve accessibility. As a result, WHO and the International Atomic Energy Agency (IAEA) have created a Joint Programme on Cancer Control focusing on the needs of radiotherapy equipment in developing countries.

4.10. Universal coverage

Out-of-pocket expenditure as a percentage of private expenditure on health

Definition Level of out-of-pocket expenditure expressed as a percentage of private expenditure on health

Rationale This is a core indicator of health financing systems. t contributes to understanding the relative weight of direct payments by households in total health expenditures. High out-of-pocket payments are strongly associated with catastrophic and impoverishing spending. Thus it represents a key support for equity and planning processes.

Private expenditure on health as a percentage of total expenditure on health

Definition Definition Level of private expenditure on health expressed as a percentage of total expenditure on health.

Rationale This is a core indicator of health financing systems. This indicator contributes to understanding the relative weight of private entities in total expenditure on health. It includes expenditure from pooled resources with no government control, such as voluntary health insurance, and the direct payments for health by corporations (profit, non-for-profit and NGOs) and households. As a financing agent classification, it includes all sources of funding passing through these entities, including any donor (funding) they use to pay for health.

5. Specific programmes and services

5.1. HIV/AIDS

http://www.aho.afro.who.int/en/data-statistics/hivaids

Estimated antiretroviral therapy coverage among people living with HIV (%)

Definition The percentage of adults and children with HIV infection currently receiving antiretroviral combination therapy in accordance with the nationally approved treatment protocols (or WHO/UNAIDS standards) among the estimated number of adults and children with HIV infection. Numerator: Number of adults and children with HIV infection who are currently receiving antiretroviral combination therapy in accordance with the nationally approved treatment protocol (or WHO/UNAIDS standards) at the end of the reporting period. Denominator: Estimated number of adults and children with HIV infection.

Rationale Antiretroviral therapy (ART) has been shown to reduce mortality among those infected and efforts are being made to make it more affordable within low- and middle-income countries. This indicator assesses the progress in providing antiretroviral combination therapy to all people with HIV infection. As the HIV epidemic matures, increasing numbers of people are reaching advanced stages of HIV infection. Over recent years WHO has issued various updates in the ARV guidelines. Under the 2013 WHO consolidated guidelines, roughly 85% people living with HIV would be eligible for treatment in 2013. For reasons of comparability across countries and over time in the context of changing recommendations, this indicator relates to the number of people receiving ART as of proportion of the overall estimated number of people living with HIV. The ranges around the levels of people living with HIV who received ART are based on the uncertainty bounds around the estimates of people living with HIV.

Estimated number of people aged 15 years and over who received HIV testing and counselling during the last 12 months per 1000 adults

Definition Estimated number of people aged 15 years and over who received HIV testing and counselling during the last 12 months per 1000 adults.

Rationale In order to protect themselves and to prevent infecting others, it is important for individuals to know their HIV status. Knowledge of one’s status is also a critical factor in the decision to seek treatment.

HIV prevalence among adults aged 15-49 years (%)

Definition The estimated number of adults aged 15-49 years with HIV infection, whether or not they have developed symptoms of AIDS, expressed as per cent of total population in that age group.

Rationale HIV and AIDS has become a major public health problem in many countries and monitoring the course of the epidemic and impact of interventions is crucial. Both the Millennium Development Goals (MDG) and the United Nations General Assembly Special Session on HIV and AIDS (UNGASS) have set goals of reducing HIV prevalence.

Population aged 15-24 years with comprehensive correct knowledge of HIV/AIDS (%)

Definition Percentage of young people aged 15–24 who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission

Rationale HIV epidemics are perpetuated through primarily sexual transmission of infection to successive generations of young people. Sound knowledge about HIV and AIDS is an essential pre-requisite — albeit, often an insufficient condition — for adoption of behaviours that reduce the risk of HIV transmission. The purpose of this indicator is to assess progress towards universal knowledge of the essential facts about HIV transmission.

Prevalence of condom use by adults (aged 15-49 years) during higher-risk sex (%)

Definition Percentage of women and men aged 15–49 who have had more than one sexual partner in the past 12 months who report the use of a condom during their last sexual intercourse

Rationale Condom use is an important measure of protection against HIV, especially among people with multiple sexual partners. The purpose of this indicator is to assess progress towards preventing exposure to HIV through unprotected sex with non-regular partners.

5.2. Tuberculosis

http://www.aho.afro.who.int/en/data-statistics/tuberculosis

Case detection rate for all forms of tuberculosis

Definition The proportion of estimated new and relapse tuberculosis (TB) cases detected in a given year under the internationally recommended tuberculosis control strategy. The term “case detection”, as used here, means that TB is diagnosed in a patient and is reported within the national surveillance system, and then to WHO. The term “rate” is used for historical reasons; the indicator is actually a ratio (expressed as percentage) and not a rate.

Rationale It provides an indication of the effectiveness of national tuberculosis (TB) programmes in finding, diagnosing and treating people with TB. WHO does not recommend that countries set specific targets for the case detection rate for all forms of TB because the denominator (estimated number of incident TB cases during a calendar year) is not directly measureable and there is thus considerable uncertainty about its true value.

Definition The estimated number of deaths attributable to tuberculosis (TB) in a given year, expressed as the rate per 100 000 population. Published values are rounded to three significant figures. Uncertainty bounds are provided in addition to best estimates.

Rationale Incidence, prevalence and mortality are the three main indicators used to assess the burden of disease caused by TB. Of the three, mortality is the only indicator that can be directly measured in all countries (provided vital registration systems are in place).Target 6.c of the Millennium development Goals is to “have halted by 2015 and begun to reverse the incidence of malaria and other major diseases”. Indicator 6.9 is defined as “incidence, prevalence and death rates associated with TB”. The Stop TB Partnership has set a target of halving the 1990 TB mortality rate by 2015.

Estimated prevalence of tuberculosis (per 100 000 population)

Definition The number of cases of tuberculosis (all forms) in a population at a given point in time (the middle of the calendar year), expressed as the rate per 100 000 population. It is sometimes referred to as “point prevalence”. Estimates include cases of TB in people with HIV. Published values are rounded to three significant figures. Uncertainty bounds are provided in addition to best estimates. See Annex 1 of the WHO global tuberculosis control report http://www.who.int/tb/publications/global_report/en/

Rationale Incidence, prevalence and mortality are the three main indicators used to assess the burden of disease caused by TB. Target 6.c of the Millenium development Goals is to “have halted by 2015 and begun to reverse the incidence of malaria and other major diseases”. Indicator 6.9 is defined as “incidence, prevalence and death rates associated with TB”. The Stop TB Partnership has set a target of halving the 1990 TB prevalence and mortality rates by 2015.

Estimated incidence of tuberculosis (per 100 000 population)

Definition The estimated number of new and relapse tuberculosis (TB) cases arising in a given year, expressed as the rate per 100 000 population. All forms of TB are included, including cases in people living with HIV. Published values are rounded to three significant figures. Uncertainty bounds are provided in addition to best estimates. See Annex 1 of the WHO global tuberculosis control report http://www.who.int/tb/publications/global_report/en/

Rationale Incidence (cases arising in a given time period, usually one year) gives an indication of the burden of TB in a population, and of the size of the task faced by a national TB control programme. Incidence can change as the result of changes in transmission (the rate at which people become infected with Mycobacterium tuberculosis), or changes in the rate at which people infected with Mycobacterium tuberculosis develop TB disease (e.g. as a result of changes in nutritional status or of HIV infection). Because TB can develop in people who became infected many years previously, the effect of TB control on incidence is less rapid than the effect on prevalence or mortality.

Tuberculosis treatment success rate

Definition The proportion of cases registered in a given year (excluding cases placed on a second-line drug regimen) that successfully completed treatment whether with or without bacteriological evidence of success.

Rationale Treatment success is an indicator of the performance of national TB programmes.

5.3. Malaria

Children aged <5 years with fever who received treatment with any antimalarial (%)

Definition Percentage of children aged < 5 years with fever in malaria-risk areas being treated with effective antimalarial drugs.

Rationale Prompt treatment with effective antimalarial drugs for children with fever in malaria-risk areas is a key intervention to reduce mortality. In addition to being listed as a global Millennium Development Goals Indicator under Goal 6, effective treatment for malaria is also identified by WHO, UNICEF, and the World Bank as one of the main interventions to reduce the burden of malaria in Africa. In areas of sub-Saharan Africa with stable levels of malaria transmission, it is essential that prompt access to treatment is ensured to prevent the degeneration of malaria from its onset to a highly lethal complicated picture. This requires drug availability at household or community level and, for complicated cases, availability of transport to the nearest equipped facility.

Children aged <5 years sleeping under insecticide-treated nets (%)

Definition Percentage of children under five years of age in malaria endemic areas who slept under an insecticide-treated nets (ITN) the previous night.

Rationale In areas of intense malaria transmission, malaria-related morbidity and mortality are concentrated in young children, and the use of insecticide-treated nets (ITN) by children under 5 has been demonstrated to considerably reduce malaria disease incidence, malaria-related anaemia and all cause under 5 mortality. In addition to being listed as an MDG indicator under Goal 6, the use of ITNs is identified by WHO as one of the main interventions to reduce the burden of malaria.

Number of insecticide classes to which resistance was reported

Definition Number of insecticide classes to which resistance was confirmed via standard bioassays for any malaria vector species collected from any site within the country and tested with any insecticide of that class during the year indicated.

Rationale This indicator belongs to a set of indicators whose purpose is to assess mosquito resistance to the insecticide classes recommended by WHO for malaria vector control, and also to facilitate implementation of the Global Plan for Insecticide Resistance Management in malaria vectors (GPIRM). WHO currently recommends four classes of insecticide for indoor residual spraying (pyrethroids, organochlorines, carbamates and organophosphates) and one for insecticide-treated nets (pyrethroids). The increasing trend in resistance to one or more insecticides classes constitutes a major threat to the effectiveness of current malaria control efforts. Therefore, resistance testing and monitoring are required to support the formulation of comprehensive national insecticide resistance monitoring and management plans for all countries with ongoing malaria transmission. This indicator provides information about the presence of confirmed carbamate resistance across countries over time.

5.4. Immunization and vaccines

BCG immunization coverage among 1-year-olds (%)

Definition The percentage of one-year-olds who have received one dose of bacille Calmette-Guérin (BCG) vaccine in a given year.

Rationale Immunization is an essential component for reducing under-five mortality. Immunization coverage estimates are used to monitor coverage of immunization services and to guide disease eradication and elimination efforts. It is a good indicator of health system performance.

Definition The percentage of one-year-olds who have received three doses of the combined diphtheria, tetanus toxoid and pertussis vaccine in a given year.

Rationale Immunization is an essential component for reducing under-five mortality. Immunization coverage estimates are used to monitor coverage of immunization services and to guide disease eradication and elimination efforts. It is a good indicator of health system performance.

Hepatitis B (HepB3) immunization coverage among 1-year-olds (%)

Definition The percentage of one-year-olds who have received three doses of hepatitis B vaccine in a given year.

Rationale Immunization is an essential component for reducing under-five mortality. Immunization coverage estimates are used to monitor coverage of immunization services and to guide disease eradication and elimination efforts. It is a good indicator of health system performance.

Hib (Hib3) immunization coverage among 1-year-olds (%)

Definition The percentage of one-year-olds who have received three doses of Haemophilus influenzae type B vaccine in a given year.

Rationale Immunization is an essential component for reducing under-five mortality. Immunization coverage estimates are used to monitor coverage of immunization services and to guide disease eradication and elimination efforts. It is a good indicator of health system performance.

Measles (MCV) immunization coverage among 1-year-olds (%)

Definition The percentage of children under one year of age who have received at least one dose of measles-containing vaccine in a given year. For countries recommending the first dose of measles vaccine in children over 12 months of age, the indicator is calculated as the proportion of children less than 12-23 months of age receiving one dose of measles-containing vaccine.

Rationale Immunization is an essential component for reducing under-five mortality. Immunization coverage estimates are used to monitor coverage of immunization services and to guide disease eradication and elimination efforts. It is a good indicator of health system performance. Percentage of children under one year of age immunized against measles is one of MDG indicators (see 3.1. MDG-4: Reduce child mortality)

Neonates protected at birth against neonatal tetanus (%)

Definition The proportion of neonates in a given year that can be considered as having been protected against tetanus as a result of maternal immunization.

Rationale Immunization is an essential component for reducing under-five mortality. Immunization coverage estimates are used to monitor coverage of immunization services and to guide disease eradication and elimination efforts. It is a good indicator of health system performance.

Polio (Pol3) immunization coverage among 1-year-olds (%)

Definition The percentage of one-year-olds who have received three doses of polio vaccine in a given year.

Rationale Immunization is an essential component for reducing under-five mortality. Immunization coverage estimates are used to monitor coverage of immunization services and to guide disease eradication and elimination efforts. It is a good indicator of health system performance.

5.5. Child and adolescent health

Children aged <5 years sleeping under insecticide-treated nets (%)

Definition Percentage of children under five years of age in malaria endemic areas who slept under an insecticide-treated nets (ITN) the previous night.

Rationale In areas of intense malaria transmission, malaria-related morbidity and mortality are concentrated in young children, and the use of insecticide-treated nets (ITN) by children under 5 has been demonstrated to considerably reduce malaria disease incidence, malaria-related anaemia and all cause under 5 mortality. In addition to being listed as an MDG indicator under Goal 6, the use of ITNs is identified by WHO as one of the main interventions to reduce the burden of malaria.

Stunting prevalence in children aged < 5 years (%)

Definition Data are derived from re-analysis of Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) micro-data which are publicly available using the standard indicator definitions as published in DHS or Unicef documentation. The analysis was done by the International Center for Analysis and Monitoring of Equity in Health and Nutrition based in the Federal University of Pelotas, Brazil.

Rationale The percentage of stunting (defined as more than two standard deviations below the median height-for-age of the WHO Child Growth Standards) among children aged five years or younger. Numerator: Number of children aged five years or younger that meet the criteria for stunting. Denominator: Total number of children aged five years or younger surveyed.

Children aged < 5 years underweight (%)

Definition Percentage of underweight (weight-for-age less than -2 standard deviations of the WHO Child Growth Standards median) among children aged 0-5 years.

Rationale This indicator belongs to a set of indicators whose purpose is to measure nutritional imbalance and malnutrition resulting in undernutrition (assessed by underweight, stunting and wasting) and overweight. Child growth is the most widely used indicator of nutritional status in a community and is internationally recognized as an important public-health indicator for monitoring health in populations. In addition, children who suffer from growth retardation as a result of poor diets and/or recurrent infections tend to have a greater risk of suffering illness and death.

Wasting prevalence in children aged < 5 years (%)

Definition Data are derived from re-analysis of Demographic and Health Surveys (DHS) micro-data which are publicly available using the standard indicator definitions as published in DHS documentation. The analysis was done by the International Center for Analysis and Monitoring of Equity in Health and Nutrition based in the Federal University of Pelotas, Brazil.

Rationale The percentage of wasting (defined as more than two standard deviations below the median weight-for-height of the WHO Child Growth Standards) among children aged five years or younger. Numerator: Number of children aged five years or younger that meet the criteria for wasting. Denominator: Total number of children aged five years or younger surveyed.

Children aged < 5 years with ARI symptoms taken to a health facility (%)

Definition Proportion of children aged 0–59 months who had ‘presumed pneumonia’ (ARI) in the previous 2 weeks and were taken to an appropriate health-care provider. Strictly speaking, ‘ARI’ stands for ‘acute respiratory infection’. During the UNICEF/WHO Meeting on Child Survival Survey-based Indicators, held in New York, 17–18 June 2004, it was recommended that ARI be described as ‘presumed pneumonia’ to better reflect probable cause and the recommended interventions. The definition of ARI used in the Demographic and Health Surveys (DHS) and in the Multiple Indicator Cluster Surveys (MICS) was chosen by the group and is based on mothers’ perceptions of a child who has a cough, is breathing faster than usual with short, quick breaths or is having difficulty breathing, excluding children that had only a blocked nose. The definition of ‘appropriate’ care provider varies between countries.

Rationale Acute respiratory infections (ARI) are responsible for 15% of all deaths of children aged less than 5 years worldwide. Appropriate care of the sick child is defined as providers that can correctly diagnose and treat pneumonia. The proportion of under-fives with ARI that are taken to an appropriate health-care provider is therefore a key indicator for coverage of intervention and care-seeking, and provides critical inputs to the monitoring of progress towards child survival-related Millennium Development Goals and Strategies.

Children aged <5 years with ARI symptoms receiving antibiotics (%)

Rationale Pneumonia accounts for an estimated 15% of deaths among children under five. Appropriate care of the sick child is defined as providers that can correctly diagnose and treat pneumonia. Antibiotics have an essential role in reducing deaths due to pneumonia. Pneumonia prevention and treatment is therefore essential to the achievement of MDG4.

Definition Proportion of children aged 0–59 months who had diarrhoea in the previous 2 weeks and were treated with oral rehydration salts or an appropriate household solution (ORT). According to DHS, the term(s) used for diarrhoea should encompass the expressions used for all forms of diarrhoea, including bloody stools (consistent with dysentery), watery stools, etc. It encompasses the mother`s definition as well as the ‘local term(s)’. The definition of “appropriate household solution” may vary between countries.

Rationale Diarrhoeal diseases remain one of the major causes of mortality among under-fives, accounting for more than 600 000 child deaths worldwide, despite all the progress in its management and the undeniable success of the oral rehydration therapy (ORT). Therefore monitoring of the coverage of this very cost-effective intervention is crucial for the monitoring of progress towards the child survival-related Millennium Development Goals and Strategies.

Children aged <5 years with fever who received treatment with any antimalarial (%)

Definition Percentage of children aged < 5 years with fever in malaria-risk areas being treated with effective antimalarial drugs.

Rationale Prompt treatment with effective antimalarial drugs for children with fever in malaria-risk areas is a key intervention to reduce mortality. In addition to being listed as a global Millennium Development Goals Indicator under Goal 6, effective treatment for malaria is also identified by WHO, UNICEF, and the World Bank as one of the main interventions to reduce the burden of malaria in Africa. In areas of sub-Saharan Africa with stable levels of malaria transmission, it is essential that prompt access to treatment is ensured to prevent the degeneration of malaria from its onset to a highly lethal complicated picture. This requires drug availability at household or community level and, for complicated cases, availability of transport to the nearest equipped facility.

Children aged 6-59 months who received vitamin A supplementation (%)

Definition Proportion of children aged 6–59 months who received a high-dose vitamin A supplement within the last 6 months. High dose vitamin A, according to the International Vitamin A Consultative Group (IVACG) definition, refers to “doses equal or greater than 25 000 IU”.

Rationale Supplementation with vitamin A is considered to be an important intervention for child survival owing to the strong evidence that exists for its impact on reducing child mortality among populations where vitamin A deficiency is prevalent. Therefore, measuring the proportion of children who have received vitamin A within the last 6 months is crucial for monitoring coverage of interventions towards the child survival-related Millennium Development Goals and Strategies.

Definition Proportion of infants aged 6-8 months receiving breast milk and any food, whether home-prepared or industrially processed, suitable as a complement to breast milk to satisfy the nutritional requirements of the infant.

Rationale Breast milk alone does not provide all the nutrients needed by an infant over six months of age. UNICEF and WHO recommend that all women breastfeed their children exclusively for the first six months. After this age, the introduction of complementary foods is critical to meet the protein, energy, and micronutrient needs of the child. Continuing to breastfeed with complementary feeding is also important as breastfeeding accounts for a substantial proportion of fat, vitamin A, calcium, and quality protein into the second year of life

Distribution of causes of death among children aged <5 years (%)

Definition Distribution of main causes of death among children aged < 5 years, expressed as percentage of total deaths. The causes of death refers to the concept of the ‘underlying cause of death’ as defined by ICD-10 (WHO, 1992).

Rationale The target of Millennium Development Goal 4 is to “Reduce by two thirds, from 1990 to 2015, the under-five mortality rate”. Efforts to improve child survival can be effective only if they are based on reasonably accurate information about the causes of childhood deaths. Cause-of-death information is needed to prioritize interventions and plan for their delivery, to determine the effectiveness of disease-specific interventions, and to assess trends in disease burden in relation to national and international goals.

Early initiation of breastfeeding (%)

Definition Proportion of children born in the last 24 months who were put to the breast within one hour of birth

Rationale This indicator belong to a set of indicators whose purpose is to measure infant and young child feeding practices, policies and programmes. Early initiation of breastfeeding, within one hour of birth, protects the newborn from acquiring infection and reduces newborn mortality. It facilitates emotional bonding of the mother and the baby and has a positive impact on duration of exclusive breastfeeding. When a mother initiates breastfeeding within one hour after birth, production of breast milk is stimulated. The yellow or golden first milk produced in the first days, also called colostrum, is an important source of nutrition and immune protection for the newborn.

Exclusive breastfeeding under 6 months (%)

Definition Proportion of infants 0–5 months of age who are fed exclusively with breast milk.

Rationale This indicator belong to a set of indicators whose purpose is to measure infant and young child feeding practices, policies and programmes. Infant and young child feeding practices directly affect the nutritional status and survival of children. Exclusive breastfeeding is the single most effective intervention to improve the survival of children. Improving infant and young child feeding practices is therefore critical to improved nutrition, health and development of children.

Under-five mortality rate (probability of dying by age 5 per 1000 live births)

Neonatal mortality rate (per 1000 live births)

Definition Number of deaths during the first 28 completed days of life per 1000 live births in a given year or other period.

Rationale Mortality during the neonatal period accounts for a large proportion of child deaths, and is considered to be a useful indicator of maternal and newborn neonatal health and care. Generally, the proportion of neonatal deaths among child deaths under the age of five is expected to increase as countries continue to witness a decline in child mortality.

Metadata http://www.childmortality.org/

Low-birthweight babies/newborns (%)

Definition The percentage of live births that weigh less than 2,500 g out of the total of live births during the same time period.

Rationale At the population level, the proportion of babies with a low birth weight is an indicator of a multifaceted public-health problem that includes long-term maternal malnutrition, ill health, hard work and poor health care in pregnancy. On an individual basis, low birth weight is an important predictor of newborn health and survival.

5.6. Maternal and newborn health

Antenatal care coverage - at least four visits (%)

Definition The percentage of women aged 15-49 with a live birth in a given time period that received antenatal care four or more times. Due to data limitations, it is not possible to determine the type of provider for each visit. Numerator: The number of women aged 15-49 with a live birth in a given time period that received antenatal care four or more times. Denominator: Total number of women aged 15-49 with a live birth in the same period.

Rationale Antenatal care coverage is an indicator of access and use of health care during pregnancy. The antenatal period presents opportunities for reaching pregnant women with interventions that may be vital to their health and wellbeing and that of their infants. Receiving antenatal care at least four times, as recommended by WHO, increases the likelihood of receiving effective maternal health interventions during antenatal visits. This is an MDG indicator.

Definition The percentage of HIV-infected pregnant women who received antiretroviral medicines to reduce the risk of mother-to-child transmission, among the estimated number of HIV-infected pregnant women. Numerator: Number of HIV-infected pregnant women who received antiretroviral medicines to reduce the risk of mother-to-child transmission in the last 12 months. Denominator: Estimated number of HIV-infected pregnant women in the last 12 months

Rationale In the absence of any preventative interventions, infants born to and breastfed by HIV-infected women have roughly a one-in-three chance of acquiring infection themselves. This can happen during pregnancy, during labour and delivery or after delivery through breastfeeding. The risk of mother-to-child transmission can be significantly reduced through the complementary approaches of antiretroviral regimens for the mother with or without prophylaxis to the infant, implementation of safe delivery practices and use of safer infant feeding practices. The purpose of this indicator is to assess progress in preventing mother-to-child transmission of HIV (PMTCT).

Births attended by skilled health personnel (%)

Definition The proportion of births attended by skilled health personnel. Numerator: The number of births attended by skilled health personnel (doctors, nurses or midwives) trained in providing life saving obstetric care, including giving the necessary supervision, care and advice to women during pregnancy, childbirth and the post-partum period; to conduct deliveries on their own; and to care for newborns. Denominator: The total number of live births in the same period.

Rationale All women should have access to skilled care during pregnancy and childbirth to ensure prevention, detection and management of complications. Assistance by properly trained health personnel with adequate equipment is key to lowering maternal deaths. As it is difficult to accurately measure maternal mortality, and model-based estimates of the maternal mortality ratio cannot be used for monitoring short-term trends, the proportion of births attended by skilled health personnel is used as a proxy indicator for this purpose. This is an MDG indicator.

Distribution of main causes of maternal death (%)

Infant mortality rate (deaths per 1,000 live births)

See under 2.2. Mortality

Lifetime risk of maternal death (1 in N)

Definition Lifetime risk of maternal death (1 in:)

Rationale The importance of quantifying the loss of life caused by maternal mortality in a population is widely recognized. In addition to the MMRatio and the MMRate, the lifetime risk, or probability, of maternal death in a population is another possible measure. Whereas the MMRatio and the MMRate are measures of the frequency of maternal death in relation to the number of live births or to the female population of reproductive age, the lifetime risk of maternal mortality describes the cumulative loss of human life due to maternal death over the female life course. Because it is expressed in terms of the female life course, the lifetime risk is often preferred to the MMRatio or MMRate as a summary measure of the impact of maternal mortality.

Maternal mortality ratio (per 100 000 live births)

Definition The maternal mortality ratio (MMR) is the annual number of female deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 live births, for a specified year.

Rationale Complications during pregnancy, childbirth and post-partum are a leading cause of death and disability among women of reproductive age in developing countries. The maternal mortality ratio represents the risk associated with each pregnancy, i.e. the obstetric risk. It is also a Millennium Development Goal Indicator for monitoring Goal 5, improving maternal health (see 3.2. MDG-5: Improve maternal health). The indicator monitors deaths related to pregnancy and childbirth. It reflects the capacity of the health systems to provide effective health care in preventing and addressing the complications occurring during pregnancy and childbirth.

Neonatal mortality rate (per 1000 live births)

See under 5.5. Child and adolescent health

Postnatal care visit within two days of childbirth (%)

Definition Percentage of mothers who received postnatal care within two days of childbirth. Numerator: Number of women who received postnatal care within two days of childbirth. Denominator: Total number of women ages 15-49 years with a last live birth in the x years prior to the survey (regardless of place of delivery).

Rationale The majority of maternal and newborn deaths occur within a few hours after birth, mostly within the first 48 hours. Deaths in the newborn period (first 28 days) are a growing proportion of all child deaths. Postnatal care contacts, especially within the first few days following birth, are a critical opportunity for improving maternal and newborn health and survival and for provision of information about birth spacing.

Pregnant women who received 2+ doses of IPTp for malaria during pregnancy (%)

Definition Pregnant women who received 2+ doses of Intermittent preventive therapy in pregnancy IPTp (2+ doses of SP/fansidar) for malaria during pregnancy (%).

Rationale IPTp is a public health intervention aimed at treating and preventing malaria episodes for pregnant women. The intervention builds on two tested malaria control strategies: to clear existing parasites and prevent new infections.

5.7. Gender and women’s health

Adolescent fertility rate (per 1000 girls aged 15-19 years)

Definition The annual number of births to women aged 15-19 years per 1,000 women in that age group. It is also referred to as the age-specific fertility rate for women aged 15-19.

Rationale The adolescent birth rate, technically known as the age-specific fertility rate provides a basic measure of reproductive health focusing on a vulnerable group of adolescent women. There is substantial agreement in the literature that women who become pregnant and give birth very early in their reproductive lives are subject to higher risks of complications or even death during pregnancy and birth and their children are also more vulnerable. Therefore, preventing births very early in a woman’s life is an important measure to improve maternal health and reduce infant mortality. Furthermore, women having children at an early age experience a curtailment of their opportunities for socio-economic improvement, particularly because young mothers are unlikely to keep on studying and, if they need to work, may find it especially difficult to combine family and work responsibilities. The adolescent birth rate provides also indirect evidence on access to reproductive health since the youth, and in particular unmarried adolescent women, often experience difficulties in access to reproductive health care.

Age-standardized incidence rate of cervical cancer per 100 000 population

n/a

Contraceptive prevalence (%)

Definition The percentage of women aged 15-49 years, married or in-union, who are currently using, or whose sexual partner is using, at least one method of contraception, regardless of the method used.

Rationale Contraceptive prevalence rate is an indicator of health, population, development and women’s empowerment. It also serves as a proxy measure of access to reproductive health services that are essential for meeting many of the Millennium Development Goals, especially those related to child mortality, maternal health, HIV/AIDS, and gender equality.

Women aged 20-24 that were married before the age of 18 (%)

Definition Percentage of women aged 20 to 24 years who were first married or in union before they were 18 years.

Rationale Marriage before the age of 18 is a fundamental violation of human rights. Yet among women aged 20 to 24 worldwide, one in four were child brides. Many factors interact to place a girl at risk of marriage, including poverty, the perception that marriage will provide ‘protection’, family honour, social norms, customary or religious laws that condone the practice, an inadequate legislative framework and the state of a country’s civil registration system. Child marriage often compromises a girl’s development by resulting in early pregnancy and social isolation, interrupting her schooling, limiting her opportunities for career and vocational advancement and placing her at increased risk of domestic violence. Child marriage also affects boys, but to a lesser degree than girls. - See more at: http://data.unicef.org/child-protection/child-marriage.html#sthash.09FTxfD9.dpuf

Definition Percentage of girls 0–14 years old who have undergone FGM/C (as reported by their mothers)

Rationale The United Nations considers female genital mutilation a human rights violation because of the physical and psychological impact this unnecessary procedure has on women. Obtaining timely, comparable and reliable information on Female genital mutilation/Cutting is key to efforts aimed at promoting its elimination. This is important to protect child.

Definition Percentage of women 15–49 years old who have undergone FGM/C

Rationale The United Nations considers female genital mutilation a human rights violation because of the physical and psychological impact this unnecessary procedure has on women. Obtaining timely, comparable and reliable information on Female genital mutilation/Cutting is key to efforts aimed at promoting its elimination. This is important to protect child.

Proportion of seats held by women in national parliaments (%)

Definition Number of seats held by women members in single or lower chambers of national parliaments, expressed as a percentage of all occupied seats. Seats refer to the number of parliamentary mandates, or the number of members of parliament.

Rationale This is one of MDG 3 indicator. The indicator covers the single chamber in unicameral parliaments and the lower chamber in bicameral parliaments. Women’s representation in parliaments is one aspect of women’s opportunities in political and public life, and it is therefore linked to women’s empowerment.

Metadata United Nations Population Division

Sex ratio (Women100 men)

Definition Number of females per 100 males

Metadata United Nations Population Division

Share of women in wage employment in the nonagricultural sector (%)

Definition Share of female workers in the non-agricultural sector expressed as a percentage of total employment in the sector.

Rationale This is one of MDG 3 indicator. The indicator measures the degree to which labour markets are open to women in industry and service sectors, which affects not only equal employment opportunity for women but also economic efficiency through flexibility of the labour market and, therefore, the economy’s ability to adapt to change.

Metadata http://data.worldbank.org/indicator/SL.EMP.INSV.FE.ZS

Total fertility rate (per woman)

Definition The average number of children a hypothetical cohort of women would have at the end of their reproductive period if they were subject during their whole lives to the fertility rates of a given period and if they were not subject to mortality. It is expressed as children per woman.

Unmet need for family planning (%)

Definition The proportion of women of reproductive age (15-49 years) who are married or in union and who have an unmet need for family planning, i.e. who do not want any more children or want to wait at least two years before having a baby, and yet are not using contraception.

Rationale Unmet need for family planning provides a measurement of the ability of women in achieving their desired family size and birth spacing. It also provides an indication of the success of reproductive health programmes in addressing demand for services. Unmet need complements the contraceptive prevalence rate by indicating the additional extent of need to delay or limit births. Unmet need is a rights-based measure that helps determine how well a country’s health system and social conditions support the ability of women to realize their stated preference to delay or limit births.

5.8. Ageing

http://www.aho.afro.who.int/en/data-statistics/ageing

Life expectancy at age 60 (years)

Definition The average number of years that a person of 60 years old could expect to live, if he or she were to pass through life exposed to the sex- and age-specific death rates prevailing at the time of his or her 60 years, for a specific year, in a given country, territory, or geographic area.

Rationale Life expectancy at age 60 reflects the overall mortality level of a population over 60 years. It summarizes the mortality pattern that prevails across all age groups above 60 years.

5.9. Epidemic and pandemic-prone diseases

5.10. Neglected tropical diseases

Number of reported cases of leprosy (Number of newly detected cases of leprosy)

Definition Enumeration of clinically confirmed newly detected cases of leprosy. WHO operational definition of a case of leprosy: a person showing clinical signs of leprosy, with or without bacteriological confirmation of the diagnosis, and requiring chemotherapy. This definition excludes individuals cured of the infection but having residual disabilities due to leprosy.

Rationale WHA Resolution 44.9 on elimination of leprosy as a public health problem

Number of new reported cases of Buruli ulcer

Definition A case of Buruli ulcer is defined as a person living in or having travelled to an endemic area and presenting with a painless lesion (nodule, plaque, oedema or ulcer) consistent with signs of the disease (with or without bacteriological confirmation).

Rationale WHA Resolution 57.1 on surveillance and control of Buruli ulcer.

Dracunculiasis certification status of countries at the beginning of the year

Definition It defines the status of certification of countries. WHO classifies countries as: Endemic for dracunculiasis - country or group of countries where dracunculiasis transmission occurs and where surveillance and control operations are essential; Countries at the precertification stage - group of countries have reached zero reporting of indigenous cases and where a reliable and extensive surveillance system must be maintained until certification; Countries not known to have dracunculiasis but yet to be certified - group of countries where the information obtained is not sufficiently clear to ascertain that guinea worm transmission has been definitely interrupted; Certified free of dracunculiasis - group of countries verified as free of dracunculiasis transmission and certified by WHO following the recommendation of the International Commission for the Certification of Dracunculiasis Eradication (ICCDE). Surveillance should be maintained until global eradication of dracunculiasis is declared. A country will be considered to have re-established dracunculiasis endemicity if the country has not reported an indigenous case of the disease for >3years, and subsequently indigenous transmission of laboratory confirmed cases is shown to occur in that country for three or more consecutive calendar years.

Annual incidence of dracunculiasis cases

Definition Enumeration of the new dracunculiasis cases. WHO operational definition of a case of dracunculiasis: An individual exhibiting a skin lesion or lesions with emergence of one or more guinea worms (each individual should be counted only once in a calendar year).

5.11. Noncommunicable diseases and conditions

Age-standardized mortality rate (per 100 000 population)

Definition The age-standardized mortality rate is a weighted average of the age-specific mortality rates per 100 000 persons, where the weights are the proportions of persons in the corresponding age groups of the WHO standard population.

Rationale The numbers of deaths per 100 000 population are influenced by the age distribution of the population. Two populations with the same age-specific mortality rates for a particular cause of death will have different overall death rates if the age distributions of their populations are different. Age-standardized mortality rates adjust for differences in the age distribution of the population by applying the observed age-specific mortality rates for each population to a standard population.

Probability of dying between exact ages 30 and 70 from any of cardiovascular disease, cancer, diabetes, or chronic respiratory (%)

Definition Per cent of 30-year-old-people who would die before their 70th birthday from any of cardiovascular disease, cancer, diabetes, or chronic respiratory disease, assuming that s/he would experience current mortality rates at every age and s/he would not die from any other cause of death (e.g., injuries or HIV/AIDS).

Rationale Disease burden from non-communicable diseases (NCDs) among adults - the most economically productive age span - is rapidly increasing in developing countries due to ageing and health transitions. Measuring the risk of dying from target NCDs is important to assess the extent of burden from mortality due NCDs in a population. This indicator has been selected to measure NCD mortality for the “25 by 25” NCD mortality target (see links below).

6. Key determinants

6.1. Risk factors for health

http://www.aho.afro.who.int/en/data-statistics/risk-factors-health-0

Prevalence of current tobacco use among adults aged ≥ 15 years (%)

Definition Current smoking of any tobacco product prevalence estimates, resulting from the latest adult tobacco use survey (or survey which asks tobacco use questions), which have been adjusted according to the WHO regression method for standardising described in the Method of Estimation below. “Tobacco smoking” includes cigarettes, cigars, pipes or any other smoked tobacco products. “Current smoking” includes both daily and non-daily or occasional smoking.

Rationale The prevalence of current tobacco smoking among adults is an important measure of the health and economic burden of tobacco, and provides a baseline for evaluating the effectiveness of tobacco control programmes over time. While a more general measure of tobacco use (including both smoked and smokeless products) would be ideal, data limitations restrict the present indicator to smoked tobacco. Adjusted and age-standardized prevalence rates are constructed solely for the purpose of comparing tobacco use prevalence estimates across multiple countries or across multiple time periods for the same country. These rates should not be used to estimate the number of smokers in the population.

Total alcohol per capita (15+ years) consumption of pure alcohol

Definition Total APC is defined as the total (sum of recorded APC three-year average and unrecorded APC) amount of alcohol consumed per adult (15+ years) over a calendar year, in litres of pure alcohol. Recorded alcohol consumption refers to official statistics (production, import, export, and sales or taxation data), while the unrecorded alcohol consumption refers to alcohol which is not taxed and is outside the usual system of governmental control. In circumstances in which the number of tourists per year is at least the number of inhabitants, the tourist consumption is also taken into account and is deducted from the country’s recorded APC.

Rationale The total APC comprises both the recorded and the unrecorded APC, which together provide a more accurate estimate of the level of alcohol consumption in a country, and as a result, portray trends of alcohol consumption in a more precise way.

Physical inactivity (WPRO)

Definition ADULTS: Prevalence of insufficiently physically active persons aged 18+ years (defined as less than 150 minutes of moderate-intensity activity per week, or equivalent). ADOLESCENTS: Prevalence of insufficiently physically active adolescents (defined as less than 60 minutes of moderate to vigorous intensity activity daily). Countries will select the relevant age group for adolescents as per their national context.

Rationale The cut-point of less than 150 minutes of moderate activity per week (or equivalent) was chosen since a vast and strong body of scientific evidence shows that people meeting this threshold have higher levels of health-related fitness, a lower risk profile for developing a number of disabling medical conditions, and lower rates of various chronic NCDs than people who are inactive. This indicator is calculated from age-specific prevalence values of insufficient physical activity. Age standardization is done in order to control differences in population age structure over time and across countries. The lower age limit of 18 years was selected taking into consideration the nature and availability of the scientific evidence relevant to health outcomes.

6.2. The physical environment

http://www.aho.afro.who.int/en/data-statistics/physical-environment

Population using improved drinking-water sources (%)

Definition The percentage of population using an improved drinking water source. An improved drinking water source, by nature of its construction and design, is likely to protect the source from outside contamination, in particular from faecal matter. Improved drinking water sources include: piped water into dwelling, plot or yard; public tap/stand pipe; tube well/borehole; protected dug well; protected spring and rainwater collection. On the other hand, unimproved drinking water sources are: unprotected drug well, unprotected spring, cart with small tank/drum, tanker truck, surface water (river, dam, lake, pond, stream, canal, irrigation channel ad any other surface water), and bottled water (if it is not accompanied by another improved source)

Rationale Access to drinking water and basic sanitation is a fundamental need and a human right vital for the dignity and health of all people. The health and economic benefits of improved water supply to households and individuals are well documented. Use of an improved drinking water source is a proxy for the use of safe drinking water.

Population using improved sanitation facilities (%)

Definition The percentage of population using an improved sanitation facility. An improved sanitation facility is one that likely hygienically separates human excreta from human contact. Improved sanitation facilities include: flush or pour-flush to piped sewer system, septic tank or pit latrine, ventilated improved pit latrine, pit latrine with slab and composting toilet. However, sanitation facilities are not considered improved when shared with other households, or open to public use. while, unimproved sanitation include: flush or pour-flush to elsewhere, pit latrine without slab or open pit, bucket, hanging toilet or hanging latrine and no facilities or bush or field (open defecation) (WHO & UNICEF, 2010.)

Rationale Access to drinking water and basic sanitation is a fundamental need and a human right vital for the dignity and health of all people. The health and economic benefits of improved sanitation facilities to households and individuals are well documented. Use of an improved sanitation facility is a proxy for the use of basic sanitation.

Population using solid fuels (%)

Definition The percentage of the population that relies on solid fuels as the primary source of domestic energy for cooking and heating.

Rationale The use of solid fuels in households is associated with increased mortality from pneumonia and other acute lower respiratory diseases among children, as well as increased mortality from chronic obstructive pulmonary disease, cerebrovascular and ischaemic heart diseases, and lung cancer among adults.

6.3. Nutrition

Children aged <5 years underweight (%)

Definition Percentage of underweight (weight-for-age less than -2 standard deviations of the WHO Child Growth Standards median) among children aged 0-5 years.

Rationale This indicator belongs to a set of indicators whose purpose is to measure nutritional imbalance and malnutrition resulting in undernutrition (assessed by underweight, stunting and wasting) and overweight. Child growth is the most widely used indicator of nutritional status in a community and is internationally recognized as an important public-health indicator for monitoring health in populations. In addition, children who suffer from growth retardation as a result of poor diets and/or recurrent infections tend to have a greater risk of suffering illness and death.

Children aged <5 years stunted (%)

Definition Percentage of stunting (height-for-age less than -2 standard deviations of the WHO Child Growth Standards median) among children aged 0-5 years

Rationale This indicator belongs to a set of indicators whose purpose is to measure nutritional imbalance and malnutrition resulting in undernutrition (assessed by underweight, stunting and wasting) and overweight. Child growth is the most widely used indicator of nutritional status in a community and is internationally recognized as an important public-health indicator for monitoring health in populations. In addition, children who suffer from growth retardation as a result of poor diets and/or recurrent infections tend to have a greater risk of suffering illness and death.

Children aged <5 years wasted (%)

Definition Percentage of (weight-for-height less than -2 standard deviations of the WHO Child Growth Standards median) among children aged 0-5 years

Rationale This indicator belongs to a set of indicators whose purpose is to measure nutritional imbalance and malnutrition resulting in undernutrition (assessed by underweight, stunting and wasting) and overweight

Metadata http://apps.who.int/gho/data/node.main.55?lang=en

Children aged <5 years overweight (%)

Definition Percentage of overweight (weight-for-height above +2 standard deviations of the WHO Child Growth Standards median) among children aged 0-5 years

Rationale This indicator belongs to a set of indicators whose purpose is to measure nutritional imbalance and malnutrition resulting in undernutrition (assessed by underweight, stunting and wasting) and overweight. Child growth is the most widely used indicator of nutritional status in a community and is internationally recognized as an important public-health indicator for monitoring health in populations. In addition, children who suffer from growth retardation as a result of poor diets and/or recurrent infections tend to have a greater risk of suffering illness and death.

6.4. Social determinants

http://www.aho.afro.who.int/en/data-statistics/social-determinants

Demography

Total fertility rate (per woman)

Definition The average number of children a hypothetical cohort of women would have at the end of their reproductive period if they were subject during their whole lives to the fertility rates of a given period and if they were not subject to mortality. It is expressed as children per woman.

Annual population growth rate (%)

Age distribution of the population (%)

Definition The percentage of de facto population aged 0-14 years in a country, area or region as of 1 July of the year indicated. The percentage of de facto population aged 15-59 years in a country, area or region as of 1 July of the year indicated. The percentage of de facto population aged 60 years and older in a country, area or region as of 1 July of the year indicated.

Resources and infrastructure

Gross national income per capita (PPP int. $)

Definition GNI is gross national income (GNI) converted to international dollars using purchasing power parity rates. An international dollar has the same purchasing power over GNI as a U.S. dollar has in the United States. GNI is the sum of value added by all resident producers plus any product taxes (less subsidies) not included in the valuation of output plus net receipts of primary income (compensation of employees and property income) from abroad. Data are in current international dollars based on the 2011 ICP round.

Poverty and income inequality

Population living on <$1 (PPP int. $) a day (%)

Definition The poverty rate at $1.25 a day is the proportion of the population living on less than $1.25 a day, measured at 2005 international prices, adjusted for purchasing power parity (PPP). Purchasing power parities (PPP) conversion factor, private consumption, is the number of units of a country’s currency required to buy the same amount of goods and services in the domestic market as a U.S. dollar would buy in the United States. This conversion factor is applicable to private consumption.

Rationale The $1.25 a day poverty line – the critical threshold value below which an individual or household is determined to be poor -- corresponds to the value of the poverty lines in the poorest countries (the poorest countries are determined by international rank of GNI per capita in PPP terms). This threshold is a measure of extreme poverty that allows for comparisons across countries when converted using PPP exchange rates for consumption. In addition, poverty measures based on an international poverty line attempt to hold the real value of the poverty line constant over time allowing for accurate assessments of progress toward meeting the goal of eradicating extreme poverty and hunger.

Gender equity

Female and male gross enrolment ratio by education level

Definition Number of students enrolled in primary, secondary and tertiary levels of education, regardless of age, as percentage of the population of official school age for the three levels. The gross enrolment ratio can be greater than 100% as a result of grade repetition and entry at ages younger or older than the typical age at that grade level (UNDP definition).

Education

Adult literacy rate (percentage aged ≥ 15 years)

Definition The percentage of population aged 15 years and over who can both read and write with understanding a short simple statement on his/her everyday life. Generally, ‘literacy’ also encompasses ‘numeracy’, the ability to make simple arithmetic calculations.

Youth literacy rate (percentage aged 15-24 years)

Definition Population and number of literates (or illiterates) aged 15 to 24 years old. Percentage of people aged 15 to 24 years who can both read and write with understanding a short simple statement on their everyday life. Generally, ‘literacy’ also encompasses ‘numeracy’, the ability to make simple arithmetic calculations. A high literacy rate among the 15 to 24 years old suggests a high level of participation and retention in primary education, and its effectiveness in imparting the basic skills of reading and writing. Because persons belonging to this age group are entering adult life, monitoring their literacy levels is important with respect to national human resources policies, as well as for tracking and forecasting progress in adult literacy. Some countries apply definitions and criteria for literacy which are different from the international standards defined above, or equate persons with no schooling to illiterates, or change definitions between censuses. Practices for identifying literates and illiterates during actual census enumeration may also vary. Errors in literacy self-declaration can affect the reliability of the statistics.

Rationale The youth literacy rate reflects the outcomes of the primary education system over the previous 10 years, and is often seen as a proxy measure of social progress and economic achievement.

Global partnerships and financial flows

Per capita official development received (US$)

Definition Net official development assistance (ODA) per capita consists of disbursements of loans made on concessional terms (net of repayments of principal) and grants by official agencies of the members of the Development Assistance Committee (DAC), by multilateral institutions, and by non-DAC countries to promote economic development and welfare in countries and territories in the DAC list of ODA recipients; and is calculated by dividing net ODA received by the midyear population estimate. It includes loans with a grant element of at least 25 percent (calculated at a rate of discount of 10 percent).

Official development assistance received as percentage of GNI

Definition Net official development assistance (ODA) consists of disbursements of loans made on concessional terms (net of repayments of principal) and grants by official agencies of the members of the Development Assistance Committee (DAC), by multilateral institutions, and by non-DAC countries to promote economic development and welfare in countries and territories in the DAC list of ODA recipients. It includes loans with a grant element of at least 25 percent (calculated at a rate of discount of 10 percent).

Total debt service as percentage of GNI

Definition Total debt service is the sum of principal repayments and interest actually paid in currency, goods, or services on long-term debt, interest paid on short-term debt, and repayments (repurchases and charges) to the IMF.

Total external debt stocks (Current US$)

Definition Total external debt is debt owed to nonresidents repayable in currency, goods, or services. Total external debt is the sum of public, publicly guaranteed, and private nonguaranteed long-term debt, use of IMF credit, and short-term debt. Short-term debt includes all debt having an original maturity of one year or less and interest in arrears on long-term debt. Data are in current U.S. dollars.

Science and technology

Percentage of population who are cellular or mobile subscribers

Definition The number of mobile cellular subscriptions is divided by the country’s population and multiplied by 100. A mobile cellular subscription refers to the subscription to a public mobile cellular service which provides access to the Public Switched Telephone Network (PSTN) using cellular technology. It includes postpaid and prepaid subscriptions and includes analogue and digital cellular systems. This should also include subscriptions to IMT-2000 (Third Generation, 3G) networks.

Population who are telephone (fixed and mobile) subscribers (%)

Definition Fixed telephone lines refer to telephone lines connecting a customer’s terminal equipment (e.g. telephone set, facsimile machine) to the public switched telephone network (PSTN) and which have a dedicated port on a telephone exchange. A fixed line has traditionally referred to the connection - typically a copper wire - from a subscriber to the telephone company’s switching exchange.